Addressing Gender Differences in Concussion Diagnosis and Treatment

Although gender equality in sports continues its steady progression, there is 1 area that appears to be linked with disparity of a different sort: A growing body of research suggests that compared with male athletes, female athletes at both the high school and collegiate levels have a higher risk for concussion and worse related outcomes.

"There is an increased frequency of concussion among females when compared to males in sports with similar rules, such as soccer and volleyball, and females tend to report more and increased severity of symptoms associated with a concussive injury than males," Vernon B. Williams, MD, founding director of the Kerlan-Jobe Center for Sports Neurology and Pain Medicine at the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, California, told Neurology Advisor.

Higher Frequency, Worse Symptoms

The difference in incidence is noted in the American Medical Society for Sports Medicine's position statement on concussion in sports, and has been supported by numerous studies.1 Most recently, research described in 2016 in the Journal of Athletic Training examined concussion injury rates of 1702 National Collegiate Athletic Association athletes participating in soccer, ice hockey, basketball, softball, baseball, and lacrosse.2 The results show that rates were 1.4 times higher among females than males in all sports except for lacrosse (injury rate, 4.84 vs 3.46, respectively), and the return-to-sports interval was longer for women vs men in both soccer, which is the sport most associated with concussion in females, and basketball.2

In addition to greater frequency, concussion-related symptoms appear to be worse in female athletes as well. Using a 22-item post-concussion symptom scale, a study published in 2013 in The Physician and Sports Medicine compared scores of males and females with sports-related concussion. No matter how soon after the injury they presented to the clinic, females had higher scores than males (30.9 vs 15.8, respectively; P <.05).3

"However, brain injury research, including sport concussion research, has long been viewed through a masculine perspective partly due to findings that [traumatic brain injury] in general occurs about twice as often in males as it does in females," said Katherine Snedaker, LCSW, executive director and founder of PINK Concussions, a nonprofit organization focused on female brain injury. "While studies show that females may have different injury rates, symptoms, and rates of recovery, the medical community does not yet have any female-specific guidelines, protocols, care plans, or education resources for women with brain injury, including concussions," she said in an interview with Neurology Advisor.

The Influence of Sex and Gender

Although the exact mechanisms are unclear, both sex and gender differences may account for the observed differences. "There are theories related to the size and strength of neck musculature, [which are] generally smaller and weaker in females, which may increase the forces experienced during contact and participation," Dr Williams explained. "There are also potential relationships to hormonal influences and even phase of the menstrual cycle that could play a role."

In a study published in 2014 in the Journal of Head Trauma Rehabilitation, for example, women who were in the high-progesterone luteal phase of their cycle at the time of injury had worse scores on measures of quality of life and neurologic functioning than those in the follicular phase or women receiving oral contraceptives.4

As for gender role influences, it is possible that "females may report more symptoms at the time of a concussive injury because they are generally more expressive or because there are fewer cultural prohibitions against 'complaining' or being unable to 'tough it out' as compared to males," according to Dr Williams. "Sociocultural influences affect reports of pain and other symptomatic conditions, so it is likely that they affect concussion reporting and the experience of symptoms as well." These aspects will need to be explored in future investigations.

Treatment Considerations

Recent findings indicate that it can take longer for female athletes to achieve symptom resolution, and that they experience more severe academic dysfunction after concussion.3,5

They may also require more treatment interventions than males; for instance, research conducted at the Connecticut Children's Medical Center found that female athletes were more likely to require academic accommodations, vestibular therapy, and medication during recovery.6

In the evaluation and treatment of concussed patients, practitioners should consider the full range of factors, including sex and gender, that "contribute critical information to the clinical picture," advises Dr Williams. "Neurologists and other clinicians evaluating and managing concussions should be aware of the very unique and individual nature of the injury."

Snedaker adds that female patients and individuals who are key to their recovery should be educated about sex differences relevant to concussion. "Since more men than women have brain injury, a woman and the people around her will most likely know more men than women who have had concussion," she noted. As such, the patient may doubt herself if her experience differs from that of affected males she might know, and family members, teachers, and employers may judge her case to be abnormal, or they may suspect malingering or the presence of issues unrelated to brain injury.

"Without proper education of [the] patient, family, and community supports, women and girls with brain injury, including concussion, can experience an additional lack of support, doubt, isolation, and anxiety beyond that which comes with brain injury," she said.